WE ARE AN EQUAL
OPPORTUNITY EMPLOYER
8570 Executive Park Ave., Fairfax, VA 22031
APPLICATION FOR EMPLOYMENT
[Please Print]
Last Name
First Name
Address
City
Middle Name
State/Zip Code
Telephone Number(s)
E-mail address
EMPLOYMENT DESIRED:
Position Applied For
Job Code
Today’s Date
How Did You Learn About Us?
Advertisement (print)
Current Employee
Walk-In
Employment Agency
Relative
Web site:
Other:
1) If you are under 16 years of age, before employment, can
you provide the required proof of your eligibility to work?
Yes
No
2) Have you ever filed an application with us before?
Yes
No
Yes
No
If yes, give date:
3) Have you ever been employed with us before?
If yes, give date:
4) Are you available to work: (check all that apply)
Full Time
Part Time
Temporary
Student/Summer
5) If an offer of employment was extended to you, on what date could you start?
6) Can you and are you willing to travel if your job requires it?
Yes
No
Yes
No
Yes
No
7) If you answered “Yes” to question #6 when can you travel?
During the day only
Occasionally overnight
Frequently overnight
8) If employment is offered, do you intend to have any type of secondary employment or self-employment?
9) Are you legally eligible to work in the United States?
(Proof of your legal right to work in the United States will be required upon employment.)
Fairfax Water – Application for Employment
10) If required, would you be willing to work (Please check one box in each category):
Overtime
Holidays
Saturday
Sunday
Rotating Shifts
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
Yes
No
11) Indicate the days or nights you are NOT available to work, if any:
12) Have you ever been terminated from employment or asked to resign by an employer?
If yes, please explain:
13) Do you have any relatives employed by this organization?
If yes, who and at what location?
14) Please list any other names that you have used in employment or in your education:
Specify name & years of use:
CRIMINAL RECORD:
Have you ever been convicted of, or pled guilty to, any felony or misdemeanor (do not list any dismissed or expunged charges)?
Yes
No
If yes, please explain:
Date
Case #
(If known)
Location: City/State
Charge
Court
Action Taken
ILLEGAL USE OF DRUGS:
Fairfax Water has a drug-free workplace policy. Are you willing to be tested for the use of illegal drugs?
Yes
No
Yes
No
Yes
No
DRIVING RECORD:
1)
Do you have a valid current license to drive a vehicle?
Driver’s License Number:
Expiration Date:
Issuing State:
Class of License:
2)
Has your license been revoked or suspended during the past seven years?
If your answer to question 2 is yes, please explain:
FAIRFAX WATER Form # 99 (December 2009)
Page 2 of 10
Fairfax Water – Application for Employment
EMPLOYMENT HISTORY:
1) Are you currently employed?
Yes
No
2) May we contact your present employer?
Yes
No
Yes
No
3) Are you currently on “lay-off” status and subject to recall?
Yes
No
4) May we contact your former employer(s)?
Yes
No
5) Are you willing to provide previous employer performance evaluations?
Yes
No
6) Will you accept an offer within the advertised hiring range?
Yes
No
If no, may we contact your present employer once an offer has been made?
If no, what range will you accept?
List all current and previous employment. List most recent position first. If numerous employers, list a minimum of seven
years history (attaching sheets if necessary). All information for each position must be provided and any gaps in your
employment history must be explained. Although some of the information requested might be on your resume, please
complete all of the employment history requested. Incomplete information may impact your application process. You
may attach your resume as a supplement to this application.
1. Company:
Other Compensation:
Co. Phone Number:
Immediate Supervisor (Name & Title):
Co. Address:
Reason for Leaving:
City/State
Duties, responsibilities, and accomplishments:
ZIP
Type of Business:
Title/Position:
Dates of Employment:
(From Month/Yr –To Month/Yr)
Base
Salary:
Start
End
Average number of hours per week?
2. Company:
Other Compensation:
Co. Phone Number:
Immediate Supervisor (Name & Title):
Co. Address:
Reason for Leaving:
City/State
Duties, responsibilities, and accomplishments:
ZIP
Type of Business:
Title/Position:
Dates of Employment:
(From Month/Yr –To Month/Yr)
Base
Salary:
Start
End
FAIRFAX WATER Form # 99 (December 2009)
Average number of hours per week?
Page 3 of 10
Fairfax Water – Application for Employment
3. Company:
Other Compensation:
Co. Phone Number:
Immediate Supervisor (Name & Title):
Co. Address:
Reason for Leaving:
City/State
Duties, responsibilities, and accomplishments:
ZIP
Type of Business:
Title/Position:
Dates of Employment:
(From Month/Yr –To Month/Yr)
Base
Salary:
Start
End
Average number of hours per week?
4. Company
:
Co. Phone Number:
Other Compensation:
Co. Address:
Reason for Leaving:
City/State
Immediate Supervisor (Name & Title):
Duties, responsibilities, and accomplishments:
ZIP
Type of Business:
Title/Position:
Dates of Employment:
(From Month/Yr –To Month/Yr)
Base
Salary:
Start
End
Average number of hours per week?
5. Company
:
Co. Phone Number:
Other Compensation:
Co. Address:
Reason for Leaving:
City/State
Immediate Supervisor (Name & Title):
Duties, responsibilities, and accomplishments:
ZIP
Type of Business:
Title/Position:
Dates of Employment:
(From Month/Yr –To Month/Yr)
Base
Salary:
Start
FAIRFAX WATER Form # 99 (December 2009)
End
Average number of hours per week?
Page 4 of 10
Fairfax Water – Application for Employment
EDUCATION AND TRAINING:
Indicate highest level of education completed:
High School
Did you graduate from H.S.?
Yes
GED?
No
Y es
Technical School
1
2
1
College/University
2
3
4
Graduate School
1
2
3
No
Name of School/College
Location:
City/State
1)
List Additional Education, Vocation, and/or Trade Information:
2)
List all Professional Licenses or Certifications:
3)
Computer Skills (Please list software):
Course
Study
Years
Completed
Did you
Graduate?
Degree
Other machines, trades, special skills or qualifications:
4)
Other Qualifications (Summarize special job-related skills and qualifications acquired from employment or other experience):
5)
State any additional information you feel may be helpful to us in considering your application:
6)
Educational gaps or additional facts for consideration:
U. S. Military Service:
Yes
No
Branch:
Rank:
Date of Discharge:
Describe any job-related training received in the United States Military:
FAIRFAX WATER Form # 99 (December 2006)
Page 5 of 10
Fairfax Water – Application for Employment
Please read carefully before signing.
I understand that neither the completion of this application nor any part of the hiring process establishes any obligation by Fairfax
Water to hire me. If I am hired, I understand that either Fairfax Water or I can terminate my employment at any time and for any
reason. I Understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with
Fairfax Water is an at-will nature, which means that the Employee may resign at any time and the Employer may discharge
the Employee at any time with or without cause. I further understand that this at-will employment relationship may not be
changed by any written document or by conduct unless such change is specifically acknowledge in writing by an authorized
executive of Fairfax Water.
I understand that Fairfax
All of the information I have given to Fairfax Water in considering me for employment is true and correct.
Water may decide to conduct substance abuse screenings, consumer credit file reviews, motor vehicle record reviews and criminal
background checks that formally may be considered an “investigative consumer report.” I authorize, to the fullest extent permitted by
law, any such substance abuse screenings, motor vehicle record reviews and/or background check or investigation directly or through
Fairfax Water’s agents, and further authorize my former employers, references, physicians and acquaintances to give any such
information they may have regarding me. I expressly agree that information from each of these sources may be used by Fairfax Water
in considering this application. In this regard, I expressly agree to sign whatever forms Fairfax Water reasonably requires, including
appropriate authorization forms, so that Fairfax Water may contact these sources and obtain relevant information about me.
I expressly acknowledge and agree that employment with Fairfax Water, if offered, may be contingent upon – if required, in the
organization’s sole discretion and to the extent permitted by law – my completion, with favorable results, of a pre-employment physical,
a review of my background and/or substance abuse screening test. In addition to the authorizations granted above, I hereby state,
certify and represent that I have read the Fair Credit Reporting Act disclosure statement provided to me and that I understand such
disclosure statement. I hereby authorize Fairfax Water and its subsidiaries and related entities to obtain and review the “investigative
consumer report” referenced in such disclosure statement.
Date:
Signature:_________________________________________
Printed Name:
FAIRFAX WATER Form # 99 (December 2006)
Page 6 of 10
Fairfax Water – Application for Employment
EMPLOYMENT CONSUMER REPORT AUTHORIZATION
I hereby affirm that my answers on my Application for Employment are true and correct and that I have not
knowingly withheld any fact or circumstance that would, if disclosed, affect my application unfavorably.
I acknowledge receipt of the Employment Consumer Report Disclosure and the summary of consumer rights
entitled, A Summary of Your Rights under the Fair Credit Reporting Act. (Pages 8-9, attached).
I authorize Fairfax Water to secure an investigative consumer report for employment purposes.
In connection with my application for employment, and for the duration of my employment, I authorize Fairfax
Water’s consumer reporting agency to verify any and all information contained in this application.
Any misrepresentation made in this application will be sufficient cause for cancellation of the application and/or for
separation from Fairfax Water if the organization employs me.
I understand that I have the right, under Section 606(B) of the federal Fair Credit Reporting Act, to make a written
request, within a reasonable time, for a complete and accurate disclosure of the nature and scope of the
investigative consumer report.
Date:
Signature:_________________________________________
Printed Name:
FAIRFAX WATER Form # 99 (December 2006)
Page 7 of 10
Fairfax Water – Application for Employment
Attention Applicant – please keep pages 8 and 9 of this application for your reference.
EMPLOYMENT CONSUMER REPORT DISCLOSURE
This disclosure is to advise you that, in the normal course of processing your employment application, Fairfax
Water may obtain an investigative consumer report for employment purposes. This report will be provided by HR
Plus (HRP) or other third party vendors as Fairfax Water determines necessary, a consumer reporting agency
which may play a part in our decision or may make recommendations to us regarding our decision.
The report provided to us by HRP, Inc. may include a consumer report for employment purposes from Credit
Information Services, which is not involved in our decision-making and which is unable to explain or provide
information regarding our decision. The investigative consumer report provided by Fairfax Water may include, but
is not necessarily limited to, the following:
Consumer credit report for employment purposes (Personal)
Criminal history records investigation
MVA driving record
Verification of education
Verification of employment history
If you have any questions regarding reports provided by HRP, Inc., you may contact them directly:
HR Plus
2902 Evergreen Pkwy.
Evergreen, CO 80439
800-332-7587
FAIRFAX WATER Form # 99 (December 2006)
Page 8 of 10
Fairfax Water – Application for Employment
Para information en espanol, visite www.ftc.gov/credit o escribe a la
FTC Consumer Response Center, Room 13 –600 Pennsylvania
Ave. N.W., Washington, D.C. 20580.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies.
There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about
check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information,
including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade
Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
• You must be told if information in your file has been
You must give your consent for reports to be provided
to employers. A consumer reporting agency may not give
out information about you to your employer, or a potential
employer, without your written consent given to the
employer. Written consent generally is not required in e
trucking industry. For more information, go to
www.ftc.gov/credit
• You have the right to know what is in your file. You
may request and obtain all the information about you in the
files of a consumer reporting agency (your “file disclosure”).
You will be required to provide proper identification, which
may include your Social Security number. In many cases,
the disclosure will be free. You are entitled to a free file
disclosure if: • a person has taken adverse action against
you because of information in your credit report; • you are
the victim of identify theft and place a fraud alert in your file;
• your file contains inaccurate information as a result of
fraud; • you are on public assistance; • you are unemployed
but expect to apply for employment within 60 days. In
addition, by September 2005 all consumers will be entitled
to one free disclosure every 12 months upon request from
each nationwide credit bureau and from nationwide
specialty consumer reporting agencies. See
www.ftc.gov/credit for additional information.
• You may limit “prescreened” offers of credit and
insurance you get based on information in your credit
report. Unsolicited “prescreened” offers for credit and
insurance must include a toll-free phone number you can
call if you choose to remove your name and address from
the lists these offers are based on. You may opt-out with the
nationwide credit bureaus at 1-888-5-OPTOUT (1-888-5678688). • You may seek damages from violators. If a
consumer reporting agency, or, in some cases, a user of
consumer reports or a furnisher of information to a
consumer reporting agency violates the FCRA, you may be
able to sue in state or federal court.
used against you. Anyone who uses a credit report or
another type of consumer report to deny your application
for credit, insurance, or employment – or to take another
adverse action against you – must tell you, and must give
you the name, address, and phone number of the agency
that provided the information.
• You have the right to ask for a credit score. Credit
scores are numerical summaries of your credit-worthiness
based on information from credit bureaus. You may request
a credit score from consumer reporting agencies that
create scores or distribute scores used in residential real
property loans, but you will have to pay for it. In some
mortgage transactions, you will receive credit score
information for free from the mortgage lender.
• You have the right to dispute incomplete or
inaccurate information. If you identify information in your
file that is incomplete or inaccurate, and report it to the
consumer reporting agency, the agency must investigate
unless your dispute is frivolous. See www.ftc.gov/credit for
an explanation of dispute procedures.
• Consumer reporting agencies must correct or delete
inaccurate, incomplete, or unverifiable information.
Inaccurate, incomplete or unverifiable information must be
removed or corrected, usually within 30 days. However, a
consumer reporting agency may continue to report
information it has verified as accurate.
• Consumer reporting agencies may not report
outdated negative information. In most cases, a
consumer reporting agency may not report negative
information that is more than seven years old, or
bankruptcies that are more than 10 years old.
• Access to your file is limited. A consumer reporting
agency may provide information about you only to people
with a valid need -- usually to consider an application with a
creditor, insurer, employer, landlord, or other business. The
FCRA specifies those with a valid need for access.
• Identity theft victims and active duty military personnel
have additional rights. For more information, visit
www.ftc.gov/credit
States may enforce the FCRA, and many states have
their own consumer reporting laws. In some cases, you
may have more rights under state law. For more
information, contact your state or local consumer
protection agency or your state Attorney General.
Federal enforcers are:
TYPE OF BUSINESS:
Consumer reporting agencies,
creditors and others not listed
below
National banks, federal
branches/agencies of foreign
banks (word "National" or
initials "N.A." appear in or after
bank's name)
Federal Reserve System
member banks (except
national banks, and federal
branches/agencies of foreign
banks)
Savings associations and
federally chartered savings
banks (word "Federal" or
initials "F.S.B." appear in
federal institution's name)
Federal credit unions (words
"Federal Credit Union" appear
in institution's name)
State-Chartered banks that
are not members of the
Federal Reserve System
Air, surface, or rail common
carriers regulated by former
Civil Aeronautics Board or
Interstate Commerce
Commission
Activities subject to the
Packers and Stockyards Act,
1921
FAIRFAX WATER Form # 99 (December 2006)
CONTACT:
FTC Consumer Response
Center - FCRA Washington,
DC 20580 (877-382-4357)
Office of the Comptroller of the
Currency Compliance
Management, Mail Stop 6-6
Wash, DC 20219 (800-6136743)
Federal Reserve Board
Division of Consumer &
Community Affairs Wash DC
20551 (202-452-3693)
Office of Thrift Supervision
Consumer Complaints
Washington, DC 20552 (800842-6929)
National Credit Union Admin.
1775 Duke St. Alexandria, VA
22314 (703-519-4600)
Federal Deposit Insurance
Corp. Consumer Response
Center, 2345 Grand Ave.,
Suite 100, Kansas City, MO
64108 1-877-275-3342
Dept. of Transportation, Office
of Financial Management,
Washington, DC 20590 202366-1306
Dept. of Agriculture, Office of
Deputy Administrator –
GIPSA, Washington, DC
20250
Page 9 of 10
Fairfax Water – Application for Employment
FAIRFAX WATER
APPLICANT AFFIRMATIVE ACTION DATA FORM
Fairfax Water is pursuing an affirmative action program to ensure equal employment opportunity in its hiring practices.
We are asking you to help measure the effectiveness of our program by answering the questions below. THIS FORM
WILL BE FILED SEPARATELY FROM YOUR APPLICATION AND WILL NOT BE USED TO DISCRIMINATE IN ANY
WAY IN THE EMPLOYMENT PROCESS. The completion of this form is not mandatory; however, your cooperation is
greatly appreciated. Thank you.
Position(s) applied for:
Name:
Date:
Last
SEX:
Female
First
Middle
Male
ETHNIC ORIGIN (Check only one box)
Ethnic origin is defined by the Federal Equal Employment Opportunity as follows:
A.
White
“White” – (Not of Hispanic origin) All persons having origins in any of the original
peoples of Europe, North Africa, or the Middle East.
B.
Black
“Black” – (Not of Hispanic origin) All persons having origins in any of the Black
racial groups of Africa.
C.
Hispanic
“Hispanic” – All persons of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish culture or origin, regardless of race.
D.
Asian or Pacific Islanders
“Asian or Pacific Islanders” – All persons having origins in any of the original
peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific
Islands. This area includes, for example, China, Japan, Korea, the Philippine
Islands, and Samoa.
E.
American Indian or
Alaskan Native
“American Indian or Alaskan Native” – All persons having origins in any of the
original peoples of North America, and who maintain cultural identification
through tribal affiliation or community recognition.
VETERAN (check all that apply):
Vietnam Veteran
Other Protected Veteran
means a veteran who served on active duty in the U.S. Military during a war or in
a campaign or expedition for which a campaign badge has been authorized listed
at http://www.opm.gov/veterans/html/vgmedals2.htm.
Special Disabled Veterans
means a veteran of the U.S. Military entitled to compensation under laws
administered by the Department of Veteran Affairs for a disability rated at 30
percent or more (or 10 - 20 percent if deemed to have a serious employment
handicap) or a discharge from duty on account of a service-connected disability.
Newly Separated Veteran
means any veteran discharged or released from active duty within one year.
FAIRFAX WATER Form # 99 (December 2006)
Page 10 of 10